Untreated preoperative depression is not associated with postoperative arrhythmias in CABG patients.

PURPOSE: The mechanism by which depression affects postoperative outcome may involve arrhythmias. The purpose of this study was to evaluate whether untreated depression is associated with an increased incidence of postoperative arrhythmias in patients undergoing coronary artery bypass graft surgery (CABG). METHODS: One hundred seven patients were assessed for signs of depression with the Prime-MD Patient Health Questionnaire (brief PHQ) one week before surgery and subsequently underwent Holter monitoring for 48-72 hr postoperatively. The incidences of atrial fibrillation (AF); supraventricular tachycardia (SVT); ventricular tachycardia (VT), defined as three or more consecutive beats at a cycle length less than 600 msec; ventricular fibrillation (VF); and average heart rate (HR) were recorded in patients with and without signs of depression. RESULTS: The incidence of preoperative untreated depression was 27% (29/107). Twenty patients had mild depression (brief PHQ score of 5-9), seven patients had moderate depression (a score of 10-14), and two patients had severe depression (a score of 20). The incidences of postoperative AF, SVT, and non-sustained VT in depressed and non-depressed patients were 37.9% vs 35.9%, respectively (P = 0.50), 34.4% vs 52.5%, respectively (P = 0.07), and 17.2% vs 37.1%, respectively (P = 0.04). The average (SD) postoperative HR was similar in both groups [95 (12) beats·min(-1) in depressed patients and 92 (10) beats·min(-1) in non-depressed patients, (P = 0.25)]. Multivariate regression analysis showed that older age, but not depression, was a risk factor for postoperative arrhythmia. CONCLUSIONS: Preoperative untreated depression is not related to postoperative arrhythmia in the early postoperative period in patients undergoing elective CABG. This trial was registered at clinicaltrials.gov (number: NCT00622024).

Isocapnic hyperpnoea shortens postanesthetic care unit stay after isoflurane anesthesia.

BACKGROUND: We conducted a prospective controlled clinical trial of the effect of isocapnic hyperpnoea (IH) on the times-to-recovery milestones in the operating room (OR) and postanesthetic care unit (PACU) after 1.5 to 3 hours of isoflurane anesthesia. METHODS: Thirty ASA grade I-III patients undergoing elective gynecological surgery were randomized at the end of surgery to either IH or the conventional recovery (control). Six patients with duration of anesthesia of <90 minutes were excluded from the analysis. The anesthesia protocol included propofol, fentanyl, morphine, rocuronium, and isoflurane in air/O(2). Unpaired t tests and analyses of variance were used to test for differences in times-to-recovery indicators between the two groups. RESULTS: The durations of anesthesia in IH and control groups were 140.8 + or - 32.7 and 142 + or - 55.6 minutes, respectively (P = 0.99). The time to extubation was much shorter in the IH group than in the control group (6.6 + or - 1.6 (SD) vs. 13. 6 + or - 3.9 minutes, respectively; P < 0.01). The IH group also had shorter times to eye opening (5.8 + or - 1.3 vs. 13.7 + or - 4.5 minutes; P < 0.01), eligibility for leaving the OR (8.0 + or - 1.7 vs. 17.4 + or - 6.1 minutes; P < 0.01), and eligibility for PACU discharge (74.0 + or - 16.5 vs. 94.5 + or - 14.7 minutes; P < 0.01). There were no differences in other indicators of recovery. CONCLUSION: IH accelerates recovery after 1.5 to 3 hours of isoflurane anesthesia and shortens OR and PACU stay.

Preoperative use of statins is associated with reduced early delirium rates after cardiac surgery.

BACKGROUND: Delirium is an acute deterioration of brain function characterized by fluctuating consciousness and an inability to maintain attention. Use of statins has been shown to decrease morbidity and mortality after major surgical procedures. The objective of this study was to determine an association between preoperative administration of statins and postoperative delirium in a large prospective cohort of patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS: After Institutional Review Board approval, data were prospectively collected on consecutive patients undergoing cardiac surgery with cardiopulmonary bypass from April 2005 to June 2006 in an academic hospital. All patients were screened for delirium during their hospitalization using the Confusion Assessment Method in the intensive care unit. Multivariable logistic regression analysis was used to identify independent perioperative predictors of delirium after cardiac surgery. Statins were tested for a potential protective effect. RESULTS: Of the 1,059 patients analyzed, 122 patients (11.5%) had delirium at any time during their cardiovascular intensive care unit stay. Administration of statins had a protective effect, reducing the odds of delirium by 46%. Independent predictors of postoperative delirium included older age, preoperative depression, preoperative renal dysfunction, complex cardiac surgery, perioperative intraaortic balloon pump support, and massive blood transfusion. The model was reliable (Hosmer-Lemeshow test, P = 0.3) and discriminative (area under receiver operating characteristic curve = 0.77). CONCLUSIONS: Preoperative administration of statins is associated with the reduced risk of postoperative delirium after cardiac surgery with cardiopulmonary bypass.

Prevalence of claustrophobia and magnetic resonance imaging after coronary artery bypass graft surgery.

BACKGROUND: The purpose of this study was to determine the prevalence of claustrophobia in patients undergoing magnetic resonance imaging (MRI) after coronary artery bypass graft (CABG) surgery. METHODS: After IRB approval, we conducted a substudy of a prospective randomized controlled clinical trial of 311 patients evaluating administration of tranexamic acid and early saphenous vein graft patency with MRI after conventional CABG surgery. Chest tube drainage was measured at 6, 12, and 24 hours after surgery. The rate of transfusion and the amount of red blood cells (RBC), fresh frozen plasma (FFP), and platelets transfused were recorded. RESULTS: A total of 237(76%) patients underwent MRI after surgery. 39 (14%, [95% CI, 10.2 to 18.0]) patients experienced severe anxiety caused by a fear of enclosed space in the MRI coil necessitating termination of the procedure. Patients with claustrophobia were on average 5 years younger. They were more likely to have diabetes mellitus and hypertension. Patients with claustrophobia had increased chest tube drainage during the postoperative period. The rate of blood product transfusion was similar between the two groups but patients with claustrophobia who were transfused received significantly more RBC and FFP than patients without claustrophobia. CONCLUSIONS: Postoperative claustrophobia and anxiety, leading to inability to undergo MRI, may be more common than previously described.

Aortic arch atheroma: stroke reduction in cardiac surgical patients.

Cardiac surgery is increasingly performed on elderly patients with extensive coronary artery abnormalities who have impaired left ventricular function, decreased physiologic reserve, and multiple comorbid conditions. Considerable numbers of these patients develop perioperative neurologic complications ranging from subtle cognitive dysfunction to more evident postoperative confusion, delirium, and, less commonly, clinically apparent stroke. Magnetic resonance imaging studies have elucidated that a considerable number of patients have new ischemic brain infarcts, particularly after conventional coronary artery bypass graft surgery. Mechanisms of cerebral injury during and after cardiac surgery are discussed. Intraoperative transesophageal echocardiography and epiaortic scanning for detection of atheromatous disease of the proximal thoracic aorta is paramount in identifying patients at high risk from neurologic injury. It is important to recognize that our efforts to minimize neurologic injury should not be limited to the intraoperative period. Particular efforts should be directed to temperature management, glycemia control, and pharmacologic neuroprotection extending into the postoperative period. Preoperative magnetic resonance angiography may be of value for screening patients with significant atheroma of the proximal thoracic aorta. It is likely that for patients with no significant atheromatous disease, conventional coronary artery revascularization is the most effective long-term strategy, whereas patients with atheromatous thoracic aorta may be better managed with beating heart surgery, hybrid techniques, or medical therapy alone. Patient stratification based on the aortic atheromatic burden should be addressed in future trials designed to tailor treatment strategies to improve long-term outcomes of coronary heart disease and reduce the risks of perioperative neurologic injury.

Chronic exposure to nicotine does not prevent neurocognitive decline after cardiac surgery.

OBJECTIVE: To establish the association between smoking and cognitive decline in patients undergoing coronary artery bypass graft (CABG) surgery. DESIGN: Retrospective review. SETTING: Referral center for cardiothoracic surgery at a university hospital. PARTICIPANTS: Four hundred seventeen patients undergoing CABG surgery. INTERVENTIONS: Based on preoperative data, patients were divided into 2 groups: smokers (n = 185) and nonsmokers (n = 232). Patients who smoked half a pack of cigarettes per day within the last 2 years were identified as smokers, and patients who did not smoke were included in the nonsmoker group. Patients with less than a seventh grade education; an inability to read; or a history of one of the following medical conditions: prior stroke with residual deficit, psychiatric illness, renal disease (creatinine > 2.0 mg/dL), or active liver disease; or patients who quit smoking prior to surgery were excluded from the study. Both groups received similar anesthetic and surgical management. All patients received a battery of neurocognitive tests both preoperatively and 6 weeks after CABG surgery. Neurocognitive test scores were separated into 4 cognitive domains, with a composite cognitive index (the mean of the four domain scores) determined for each patient at every testing period. MEASUREMENTS AND MAIN RESULTS: The overall rate of cognitive decline at 6 weeks after surgery in smokers was 36.2%, whereas nonsmokers showed a deficit rate of 36.6%. Nonsmokers were significantly older and presented for surgery on average 6 years later than the smokers. Female sex represented a considerably larger proportion of patients in the nonsmoker group. Smokers had a higher prevalence of myocardial infarction. The univariate analysis of cognitive change at 6 weeks adjusted for age, baseline cognitive index, and education years showed no difference between the 2 groups. Sex, history of myocardial infarction, hypertension, stroke, transient ischemic attack, and duration of cardiopulmonary bypass did not contribute to the multivariate logistic regression model and were dropped from the final analysis. Significant multivariate predictors of neurocognitive dysfunction included age, left ventricular ejection fraction, baseline education level, and baseline cognitive index. CONCLUSIONS: This study confirmed previous findings that age, baseline cognitive function, years of education, and impaired left ventricular function are independent predictors of neurocognitive decline at 6 weeks after CABG surgery. Smoking is neither preventive nor causative of cognitive decline after CABG surgery.

Quantitative echocardiographic assessment of regional wall motion and left ventricular asynchrony with color kinesis in cardiac surgery patients.

UNLABELLED: Conventional echocardiographic interpretation of regional wall motion abnormalities is subjective and experience dependent. Delayed contraction in the ejection phase (tardokinesis) and regional systolic asynchrony, sensitive markers of myocardial ischemia, cannot be accurately assessed visually. We used color kinesis (CK), a technique that evaluates spatiotemporal patterns of endocardial motion, to objectively detect regional wall motion abnormalities in patients undergoing coronary bypass surgery, and we compared it with conventional assessment of grayscale images by less experienced reviewers; we used expert grading as the gold standard for comparisons. Quantitative CK analysis agreed more closely with expert grading than less experienced reviewers (kappa coefficients, 0.74 versus 0.52 and 0.5). Global tardokinesis, identified in 9 of 26 patients (2 with normal fractional area change), was associated with an increased index of systolic asynchrony. Regional tardokinesis was identified in 48 of 150 segments: 27 segments had a normal magnitude of wall motion, 18 were hypokinetic, and 3 were severely hypokinetic/akinetic. Mildly hypokinetic segments showed delayed systolic motion, whereas residual motion of severely hypokinetic/akinetic segments occurred in early systole, reflecting passive effects produced by adjacent myocardial contraction. Quantitative CK may be a useful supplement to visual assessment, particularly for less experienced readers. By diagnosing tardokinesis, common among cardiac surgical patients even with normal standard ejection phase indices, quantitative CK may improve the intraoperative detection of regional ischemic changes. IMPLICATIONS: Quantitative color kinesis allows for objective and sensitive intraoperative echocardiographic assessment of abnormal spatial and temporal patterns of regional ventricular wall motion, with potentially important implications for improving myocardial ischemia detection in patients undergoing cardiac surgery.

Intraoperative assessment of diastolic function: utility of echocardiography.

PURPOSE OF REVIEW: This review discusses the current and future applications of different echocardiographic modalities in evaluating diastolic function intraoperatively. RECENT FINDINGS: Normal diastolic function is required for optimal cardiac performance. There is sufficient evidence to support the significant prevalence of preoperative diastolic dysfunction and its incidence following cardiac surgery, however controversy still exists regarding the impact of diastolic dysfunction on adverse outcomes. Echocardiography provides a relatively safe, practical and noninvasive means to evaluate perioperative diastolic function, however conventional measures may be limited by the impact of changes in heart rate, rhythm and loading conditions. Newer echocardiographic modalities are reportedly less sensitive to acute changes in loading conditions, and may therefore complement the use of conventional echocardiographic techniques in the perioperative period. SUMMARY: The availability of effective technology for diagnosing the presence and progression of perioperative diastolic function should assist in the identification of high-risk cardiac surgical patients who may benefit from appropriate triaging and therapeutic intervention.

Mitral flow propagation velocity identifies patients with abnormal diastolic function during coronary artery bypass graft surgery.

UNLABELLED: Flow propagation velocity (Vp) is a new method of assessing left ventricular (LV) diastolic (D) function that seems to be insensitive to heart rate and preload changes. We hypothesized that Vp <50 cm/s identifies patients with D dysfunction and that Vp provides an assessment of D function when standard Doppler techniques are uninterpretable. We conducted a prospective Doppler echocardiographic assessment of D function in 63 patients undergoing coronary artery bypass graft surgery. Doppler derivatives of mitral inflow and pulmonary vein flow profiles as well as isovolumic relaxation time were compared with Vp before and after cardiopulmonary bypass. A Valsalva maneuver was used to decrease preload. All patients with D dysfunction had Vp <50 cm/s. A Valsalva maneuver did not affect Vp. Vp remained a reliable measure of LV D function when mitral flow profiles could not be determined because of changes in heart rate and rhythm. LV filling patterns did not change significantly after cardiopulmonary bypass. We conclude that Vp is a simple measure of D function during coronary artery bypass graft surgery that correlates with standard, load-dependent Doppler echocardiographic techniques to identify D dysfunction. Vp <50 cm/s identifies abnormal D function in this patient population. IMPLICATIONS: Mitral propagation velocity (Vp) is a simple, reproducible measure of diastolic function during coronary artery bypass graft surgery that correlates with standard Doppler echocardiographic techniques to identify dysfunction in the setting of a rapid heart rate or variable preload. Vp <50 cm/s identifies abnormal diastolic function in this patient population.